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Home My WebLink About0091 GOSNOLD STREET Alzze�M- i - i Y,�Pvv PR 3 d �of Barnstable *Permit# M- G 2 f f Expires 6 moths from issue date Regulatory Services Fee � A�RwRT�Ri.F_ s KAM $ Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town barnstable.ma us Office: 508-862-403 8 Fax:-508-i90-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number`-z7,j -Yq ` Property Address f ! �OS �G t/ l� I/ ��N/� / .►�' ❑Residential Value of Wor � d C Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name- � �/� //n�P �A?ephone Number Zg: ��_ !' 96 Home Improvement Contractor License#(if applicable) d �� Construction Supervisor's License#(if applicable) ❑Worlanan's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Namei1 / Workman's Comp.Policy# (c �T � � � -- Copy of Insurance Complianct Certificate must accompany each permit. Permit Request(check box) �e-roof(hurricane nailed)(stripping old shingles) All cgnstruction debris will be taken to E�Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ Smoke/Carbon Monoxide,detectors 4 floor plans marked with red S and inspections required. . Separate Electrical&Fire Permits required. *Where required.- Issuance of thus permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Azopy of the H Improvement Contractors License&&Construction Supervisors.License is required SIGNA . t i E.R.Mantini Construction General Construction Framing-Finish- Roofing- Decks 375, compass circle- Hyannis-ma 02601 (508) 280-0785 ermantiniconstruction@yahoo.com To: Mrs. Heather Perry 91 gosnold rd - Hyannis- ma 02601 Roof(about 22sq roofing) -Certain teed Landmark Premium Metric AR X -7"Swiftstar certainteed Universal starter j - H&R shadow ridge,certainteed Hip&Ridge i - Ridge cobra vent -#15 felt paper -3 feet ice water -Remove and install new skylight Remove the old roofing Install new roofing Disposal all the debris Permit Required - Labor and Material: Price: $ 8,600.00 Thank you for your business! PSignature Date: 5//3 1 - ivutssacnusctts- ucpaiirnent of rui)w --5aictN Board of Buildin�a Rc iulations and Standards Construction Supervisor License License: CS 57692 MARCEL DURANLEALI � 45 SILVER LANE ' " HYANNIS, MA02601 + ' �L- ..... Expiration: 9/24/2013 Commissioner Tr#: 5819 Office of Consumer Affairs&Business Regulation �,. F. OME IMPROVEMENT CONTRACTOR Registration 0473 Type t ' i. Expiration 102-7T20,1,3 Supplement ER MANTINI CONSTRdCTl0jW" it MARCEL DURALEaU + I P.O BOX 148 - a- HYANNIS,MA-02601 t Undersecretary , I.. massacnusetts- uepartmcnt or runuc MJUN` Board of Building- Re�-ulations and Standards: Construction Supervisor License License: CS 57692 w � MARCEL DURANLEAU 45 SILVER LANE ' :,°; HYANNIS,MA 02601 Expiration: 9/24/2013 Commissioner Tr#: 5819 • License or registration valid for individul use only before the expiration date. If found return to: j Office of Consumer Affairs and•Business Regulation I 10 Park Plaza-Suite 5170 -"ard Boston,MA 02116 S 3. 4 Not va without signature 77se Commomve d&of Massachuseft D4w*n t o,jlndushid Accidents Office of-Investigations ' 660 Washington Street Boston,MA 67211.1 . Workers' Compensation insurance A davi m derslContrac rs/ElectricianslPh tubers Umbly Applicant Infarmatian Pease Font Name CityfStat 2* Phone# �"� "� ✓` Are you an employer?Check a xpp apriste busy Type of proiect(required): 1.❑ I am a employer with 4- ❑ I am a general c-cn ractor and I 6- ❑New constrwfion employees(full andfospwt-Une)-* havehired$ie sub-contractors listed on the attached sheet 7• ❑Remodeling 2 I am a sole g oprie rt ar parirter- These sub-contractors have ship and have no employees S_ ❑Demolition wod ng for me in any capacity. employees and have workers' 9 ❑Budding ad&tion vrorl=1 comp-ny®4rance comp_insuraue 10 required 5, ❑ We are a corporation and its 10.❑Electrical repairs or additions 3_❑ I am a homwwner doing all work taffic exercised 1 l_❑Plumbing repairs or additions Of ors eria GL mY [Pro wodkars'camp. ewe have no 12.0 Roof repairs c..152,§1(4), insurance zegosred]T 13.❑other employees [No worriers' comp.invxance required . *Any appic=that checim box#1 m st also fmmat tine sactin¢below sbovriag their workers'rompaouh—pohcp ianfarmstim- 1 Hnuie .,ins wba submit this atfdavu 9ndic Mn9,they as &Mg nit_auk_eh_hue ou=&cont,,c rs mast wbmn a new affidavit xadxatz g sack tCm=,r om th9t ch,,k this box must attacked au,t7A;nwn,i amat showhg the name of the and state whether ar not fbose entities have ea]pleveM. Ifthe mt-rnutmaaa have employ--%,they Tmsi p ide 1h&W-keW c0mp-policg amber. I am an er rpltrJ trr that is providing.worir¢,rs'COAT LTatisn iasur mc-e for nzy empl4vem Below is the cY arid,tab site hifiorrsFradon. . insurance Company Name: �► C �J /' 7, Policy 9 or.Self ins.Lic_#: G .7 e7 ` ! _� Eimfou Date: ✓ ,� Gf' GityfStatPJT.rp Job Site Address:�.� Attach a cop} of the workers'compensation policy declaration page(showing the policy ber and eapu atie<n date). Failure to secure coverage as required under Section 25A of M10L c_ 152 can lead to the imposition of criminal penalties of a fine up to S 1500 OD an&or one-hear isnpsistsmneat�as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250-00 a day against the violator. Be whised W a Copp of this sbdement may be.fwxmded to the Office of hnes#ptivns of the DIA for nwt ance coverage verification- ' i do hereby cerli&under. and eut,T�as et f flint ifie Wonnadem prrrntr>red rg n�td/correct �i Date: Phone#: -4'1.1?1 Z-1 0ifficial use only: Do not write in this area to be cv eted by citp or City ca�Town: Perru idUcense# Issnii g Authority(circle one): . I..B&M d.of Health BUdding Department 3. S()`aysn Clerk d.£le-ctrical Fnspes#or 5.Pb�bmg Inspector 6.Utter.. ---u. ANI� TO ,qpp��AA� /�p Town of Barnstable. Permit pF r!'YS�`/° IX8 Expires months from issue dat Regulatory Services Fe BARNSTAHLE, HAM $ Thomas F.Geiler,Director ,n 0 9. prEG MP'l Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma:us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS P RMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel XurntXq Property.Address ® Residential Value of Work .7 , 1 z e DO Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address CI.P d/l_ Big. f tIyu" Contractor's Name��Q �YYliant �� c?� -. Telephone Number SO9- z_A90_195' Home Improvement Contractor License#(if applicable) r c q Construction Supervisor's License#(if applicable) CS J�� Z ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ .I am the Homeowner I . ❑ I have Worker's Compensation Insurance Insurance Company Name yc,, Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side . #of doors _ ® Replacement Windows/doors/sliders.U-Value �a 1C�Cmaximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4.floor plans marked with red S and.inspections required. Separate Electrical&Fire Permits required. - *Where required: Issuance of this permit does not exempt compliance with other town department.regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: E.R.Mantini Construction General Construction Framing-Siding-Roofing-Finish Work-Decks 375 Compass Circle- Hyannis- Ma 02601 (508) 280-0785 ermantiniconstruction@yahoo.com 10/18/2012 Estimate For: Heather Perry 91 Gosnold rd.- Hyannis- Ma Windows Replacement into the porch area " 3 Unit Size 861/4 x 43 2 Unit Size 36x43 2 Unit Size 53x43 Screen: Full Screen Fiberglass Mesh Glass: Triple Glazed, Double Low E,Argon Filled Hardware: Double locks . Performance Ratings: Energy star 1 Bay window 96.5 x 50 screen: Full Screen Mullion,fiberglass Mesh Glass: Unit 1 Lower, 1 Upper, 3 Lower, 3 Upper: double„Glazed Unit 2: Double glazed, low E,Argon Filled, DSB . 'Hardware: Double locks,Sash Limit Devices= N,igth Latch Performace Ratings: Energy Star Replacement outside porch tirms Permit requied Extra.work will be charge by the hour$45.00 Material: $ 6,600.00 Labor: $ 2,800.00 Tax: 6.25% $412.50 1 V The Commonwealth of Massachusetts Department of Indusbrgal Acciderrits Office.Of investigations 600 Washington Street Boston,.AM #2111 wnw.mr govldirr Workers' Ccfmpensation Insurance.Affidavit. B�dersf+Contractoi•sfE�ectric ansl�l�rmbers Applicant Information Please Print Lelibl . Name(Busjw ga�timftd vidval): Address: S C r e�c c2� hit/ r/-✓�. .w . City/State/Zip: S .✓ Z _o Phone# 510 f Are you an ermploy r?Check the appropriate box.: Type of project(required): 1.❑ I am a employer with I am a general:omtractor and I emlloyees(full andl'or part-time)- * have hired the sub-contractors6_ [:]New construction 2. I am a sole pmprietcri or partner- listed on the attached sheet 7. [-]Remodeling ship.and have no employees 'Deese sob-contractors have g_ ❑Demolition employees and have wa&ers' wot3�ing for mae in any capacity. 9. ❑Bulding.atlditiog o toms'comp_insurance comp:m¢nranr�.Z required] 5. ❑ We are a corporation and its 1�.❑Electrical repairs or additions aired I❑ I.am a homeowner doing all work officers have exercised dwir 11.❑Plumbing repairs or additicrs ` of exemption per NIGL myself. [No workers'comp. exeoap p 12.❑Roof repairs insurance required.]T. c. 152, §1(4),and we have no employees.[No workers' 13.❑Other rr, comp_insurance r+egiamd:}. 'Any Wplkant that checks box#1:mast also fill out the section below showing their workers'comperssation policy informstim Romeowners who submit this affidavit indicating they ue doing all work arrd then hire outside contractors mast Submit anew affidavit indicating such. tContractnn that check this box mast attached an additionsl'sheet showing the ns®e of the sub-cmv ractors and stare whether or not those entities have emplayees. if the sub-contractors hne employees,they must:pmvide their aiorken'comp.policy number. I aim an employer that is prmiding workers'compensadon insurance for MY ewplgreex Belot`is the police and job site ii�fortrtrcftsn. . Im unuice,Company flame: ?n eL..; 3�dt..c j�i� ti ASS c-e Policy or.Se1€iris.Lic.#: Expiration Date: Job Site Addiew: "Illuapd jr City/StatetZip: .M1 Attach a copy of the workers''compensation polio declaration page(showing the policy ember and expiration date). Failure to secure coverage as required under Section 25A of MGL c_ 152 can lead to the imposi#iom.of criminal penalties of a fine up to$1,500-00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to$250.00 a day against the violator_, Be advised Lthat a copy of this statement may be fix-warded to the Office,of Investigations of U DIA for insurance coverage verificatia I do h are by cepW y ender the pain s and •$s n the information provided above is true and correct 5i OleDate: ��•Z Z Phone rg q f!gS O,,ffw&l use only. Da nut ivrite in this area,to be completed by city or tonvi afficiat City or Town: Permit/License# issuing A.ntharity(circle one): 1..Board.of Health -3.BBn g'I}eparto�ent 3.City(Towd:17 rk.4.E3ec ical Inspector. .Plumhtiig H ector 6.Othesr of JHEraq. P� ti MASS.. ,�� Town of Barnstable prED MAC A Regulatory Services Thomas F. Geiler,Director Building Division - Thomas Perry,CBO. Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This.Section If Using A Builder I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit.application for: (Address of Job) Signature of Owner Date r� Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on;the rewrse.side. --_--Q:\-[PFILESYEOPMS\buildine.oermitforms\EXPRESS.doc _ J . �oFTtTti Town of Barnstable Q a� Regulatory Services snarrSTABCE Thomas F. Geiler,Director MASS. Fn . Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.ba rnstable.ma:us Office:. 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two- family dwelling, attached or detached structures accessory to such.use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) . The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. The undersigned "homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and,requirements and that he/she will comply with said procedures.and requirements. . Signature of Homeowner Approval of Building Official' Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. Y HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors)-,provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. ✓fze i�ominwnureai o�✓i�craaaclzuaea Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Registration? -0473 Type Exp"_ on = QL27-12013 Supplement ER MANTINI CON -IRU,CTIQtd MARCEL DURALEA s f P.O. BOX 148, HYANNIS:MA U601 Undersecret arry j �- ivi ts1achusetts- .130ard of g OcP.[rtment of P Build. Re- unlit S.itet. Construction Supervisor and Standarc' pervisor License License: CS 57692 MARCEL: DURANLEAV 45 SILVER LANE.'. t't . HYANNIS, MA 02601 (:ummissiuner Expiration: 9/24/2013 Tr#: 5819 _ � D ddo0 �, Z r m ►d � z < m' o .. i y rn r 0 n r� 5C� Y i '• O r" "• i v c, ,� p. 1 .. - MpG C N U1 r rn K p N n C C l r Towle of Barnstable ,ofIHErOkL Regulatory Services Thomas F. Geiler, Director BARNSTABLE, " Building Division v 1659• a Tom Perry, Building Commissioner �'preD rnA'� g 200 Main Street, Hyannis, MA 62601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# _00 t 00 -4 37 1 FEE: $V.. SHED REGISTRATION 120 square feet or less a Location of shed(address) Vi11 ge /Z;'01246 //,o ra Z 7/ Property owner's name Telephone umber Size of Shed ap/Parcel # 7/ 16 Signature Date D � C Hyannis Main Street Waterfront Historic District?- Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) FR-l1'Sgn off_.____ h�ou`s on 8�0 for-Conservati0-9.30&3 .30.30-4 _ 9 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:042506 Map Page 1 of 1 Town of Barnstable Geographic Information System New Search Home Help , Parcel Viewer Custom Map Abutters Map Size °' Zoom Out D ' L] fl fl f fl In PK IiY ' ® &- JPG Map: 324 Parcel: 084 Full � W*;;; �..; ti Property 7 32N4D017 Location: 91 GOSNOLD STREET Info 324016 324013 "LL86 Owner: MALLORY, BERNARD& N 14 324016 492 I 324014 Location Information N 114 ,,E 324096 Map &Parcel 324084 ' 1 N71 Location 91 GOSNOLD STREET ' 324097 Acreage 0.36 acres F N81 Current Owner �s.� Mailing Address MALLORY, BERNARD & TZANNOS, SANDRA F 324085 - w 91 GOSNOLD ST i N6 324084 324098z 324099 491 ® N22 HYANNIS, MA 02601 p 324006 N 121 WATSQ Appraised Value (FY 2010) N S7 Extra Features $3,300 Out Buildings $0 Land $158,600 Buildings $137,400 LU 324086 4 N 14 324111 324120 Total Appraised $299,300 324005 ' N 26 i N 23 N25 32�4083 Assessed Value (FY 2010)art 1 t _ r Extra Features $3,300 d ' Out Buildings $0 Land $158,600 -173 Buildings $137,400 Set Scale 1° = g0 I Aerial Photos I MAP DISCLAIMER Total Assessed $299,300 Copyright 2005-2010 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS BarnstableMA v1.2.3867,[Production] http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=324084 8/24/2010 �p ti Town of Barnstable *Permit# 62 2�_ p� Expires 6 months�from issue date IInaxsTABM : Regulatory Services Fee., r , ;. `0$ Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner X-PRESS PERMIT 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 - JUL 2 4 2002 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESIDENTL VW1VF BARNSTABLE Not Valid without Red X-Press Imprint Map/parcel Number Property ess �� s�Q z t�� / esidential Value of Work _ i n�4et!57• v Owner's Name&Address l / l l s f��' Contractor's Name Telephone�/Ch C,�(D ��' ePhone Number Home Improvement Contractor License#(if applicable) Z 2,r= Construction Supervisor's License#(if applicable) � ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor - ❑ I n the Homeowner ave Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box_ e-roof(stripping old shingles) All construction debris will betaken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. t Signature Q:Forms:expmtrg Revised121901 APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICAL SERVICE � G�P Inspector of Wires Wiring Permit# �� COM/Electric# 295449.; Town of A /u�� — OAR M sa`hN/�t s Building Permit # fDate 1 ' Customer: T!,12 A l/r !"L_,41—L612�`T/ on (Street#) 9911 Lot # in the village of YAA �'�, utility pole number or underground numbed Customer's billing addresses ✓ �� t q °` Temporary o New installation Change of service �� Starting date Job description f'� 'ArRADE /t/ls" O U1177" Service entrance voltage Amperage 0 Phase Wire size(cu.or a c Conductor per phase Number of meters Water heater Off peak: Yes No_,I/ Estimated load: Electric heat kw, lights kw,Range dryer Motors, H.P.&Phase Ready for first inspection /4 y GzLe r-N1AJ&' Ready for final inspection Electrical Contractor A 44b s fr' tj1/ A1-,g- Lic. # A -7,Q71 c�1.q � Telephone'# Address 94 I NlQt!lA 12 65 xe5yzl 1 M a if,S_� Additional Remarks: Do Not Write Below This Line RING INSPECTION CERTIFICATE GANSPECTOR OF WIRES INSPECTIONS a� O DATE FEE CHARGE Temporary Service Roughing in Service and Meter Off Peak Meter .a Final Approval Disapproved' "For the following reasons CERTIFICATE OF INSPECTION _ Date To the COMMONWEAL ELECTRIC.COMPANY.The installation described above has been completed and has this day been inspected and approval granted for connection to`'your service - � „ � Inspector of Wires WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION Permmit Good For One Year From Date Of Issue - CA 46 ` a¢�. INSPECTOR'S NOTICE d Office Use Only I-he Commonwealth of Afassaehuseits pen;,itN,. Department of Public Safcry Occupancy eFee Checked / BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1Z-00 3%,i (hive bLnk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK. All wrk to be performed In accordance With the Maaaachusetts Electrical Code, S27 CP4R 12: (PLEASE PRINT IN INK OR TYPE ALL INFORHMON) Date �S TOWN OF BARNSTABLL To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Number) (? J ��/J�/+� Owner or Ienant Owner's Address S � Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box) Purpose of Building/ �/i(/L' j�I _Utility Authorization NO. Existing Service ('l Amps q� ��/ //6� Volts Overhead &�Undgrd � ❑ No. of Meters New Service /OD Amps �f^7d/ 11� Volts Overhead lL/1 Undgrd ❑ No. of Haters Number of Feeders and Ampacity j ,�/ Location and Nature of Proposed Electrical Work Jr e. No. of Lighting outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool '*Z' LJ gr•+d, L J (Generators M.'VA Na o. of, Emergency Lighting No. of Receptacle Outlets No. of Oil Burners !Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Cond. tons Initiating Devices No. of Disposals No. of Heat Total Total No. of Sounding Devices Po Pumps Tons KW No. of Dishwashers S ace/Area Heating KW No. of Self Contained P _ Detection/Sounding Devices Municipal No. of Dryers Heating Devices KW Local❑ Connection[]Other No, of o. o Low Voltage No. of Water Heaters Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability nsurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO ( I have submitted valid proof of same to this office. YES❑ NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Expiration ate Estimated Value of lectrlcal Work S �O / Vork to Start Inspection Gate .Requested: Rough Signed under theme/ penalties of perjury: FI Rh .�NA _f7mOs // �Cf'dI/� I° t^�/ C% A/ LIC..vO_.. - ✓�Q-L/�C Licensee /T Signature LIC. NO. !I Address �� s. Tel. No. /r Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its su - . stantial equivalent as required by Massachusetts General ws, and that my signature on this permit ap lication waives this requirement. Owner Agent v(Please check //one) 1J/ Ielephone No. / / 1 P�77/ PERMIT FEE S(7 Signa ure of Amer o Agent